Persistent Complications Research Articles

P-1862. Rapid evolution of the Staphylococcus aureus Accessory Gene Regulator system under metabolic stress

Abstract Background The Agr system is the master virulence regulator in Staphylococcus aureus. Active Agr signaling drives acute infections such as abscesses and endocarditis, while dysfunctional signaling is associated with persistent complications and antibiotic tolerance. Agr mutants have been isolated from nares and identified during persistent invasive infections. Thus, Agr loss-of-function mutants are considered an adaptive evolutionary strategy utilized by S. aureus to maintain its presence within hosts. The mechanisms underlying its selection, however, are not well understood. We recently identified genetic and environmental metabolic factors that selects for Agr loss. Agr quorum sensing system in S. aureus The Agr system is the master virulence regulator and is encoded by the agrBDCA operon. The auto-inducing peptide AgrD is matured and transported extracellularly by the membrane protein AgrB. At high enough population density, AgrD accumulates in concentration and is able to activate the surface receptor histidine kinase AgrC, which then signals intracellularly via phosphorylation of the response regulator AgrA. AgrA is a transcription factor that both feed-forwards the agrBDCA operon, as well as driving the expression of numerous virulence factors. Methods Growth, in vitro evolution, and competitive fitness of USA300 JE2 MRSA strains were performed and analyzed in chemically defined media (CDM). The whole genomes of isolates that underwent in vitro evolution were sequenced using an Illumina platform. Agr hemolysis defect was assayed using sheep’s blood agar plates. Growth assays of mutant strains in various CDM. agr mutant strains have enhanced growth under specific amino acid stress. Results We systematically analyzed the growth of a panel of USA300 JE2 MRSA strains (WT, agr, codY, agr/codY) in CDM lacking either single or multiple amino acids. We identified two specific CDM compositions that selectively enhanced the growth kinetics of strains containing agr mutations: (-)TMYISHGF and (-)SG. Growth competition assays in the same two CDM confirmed the fitness advantage of agr mutants. To next assess the physiologic relevance of agr mutations in these media conditions, we performed in vitro evolution and found that both media led to rapid accumulation of Agr loss. We further find that the codY strain, which is deficient in the global metabolic regulator CodY, also selects for agr loss independent of media conditions. Competition assays of mutant strains in various CDM. agr mutant strains have increased growth fitness under specific amino acid stress. Only agrA/codY had increased fitness compared to WT in CDM-TMYISHGF, whereas all mutant strains have increased fitness compared to WT in CDM-SG. Mean values were compared using one-way ANOVA (*, p<0.05; ***, p<0.001; ****, p<0.0001). Conclusion Depending on its status, S. aureus Agr can either drive acute infections or establish a persistent presence. Our identification of genetic and environmental factors that facilitates this lifestyle switch provides valuable insight into how S. aureus adapts within the host during invasive disease. Elucidating the specific mechanisms involved will pave the way to the development of adjunctive anti-metabolism therapeutics that can provide protection against persistent infectious complications. In vitro evolution of agr mutants in various CDM. Tracking hemolysis loss – aka Agr loss – over time reveals both genetic and environmental influences on Agr loss. Genetically encoded codY mutations drive agr mutations via de-repression of QS signaling, whereas specific environmental nutrient stress also drives Agr loss. Disclosures All Authors: No reported disclosures

Return to Work, Sport, and Sport- Related Activity After Distal Triceps Tendon Repair: A Systematic Review.

Distal triceps tendon injuries are relatively rare injuries, often occurring in highly active patients with physically demanding jobs or lifestyles. Information on return to work, sport, and activity is essential for patient education and counseling after a distal triceps tendon rupture. To determine the rates of return to work, sport, and sport-related activity after distal triceps tendon repair. Systematic review; Level of evidence, 4. PubMed, CINAHL, MEDLINE, Web of Science, and SPORTDiscus were queried from the earliest record through January 12, 2024. Articles were included if they examined return to various activities (exercise, sport, work, or military duty) after distal triceps tendon repair. Data on return to sport/work/activity were collected as well as information on patient satisfaction, pre-existing medical history or medication use (ie, anabolic steroids or corticosteroids), and complications. Article quality was assessed via the Methodological Index for Non-Randomized Studies (MINORS) scale. Of 164 articles initially retrieved, 10 retrospective studies were included. Patients (n = 318; 74.2% male, 25.8% female) who underwent distal triceps tendon repair had a mean age of 44.7 ± 5.5 years with a mean follow-up time of 52.6 ± 21.4 months. After distal triceps tendon repair, 93.3% of patients (112/120) returned to sport, 95.3% (81/85) returned to military duty, and 92.6% (100/108) returned to work. Of the studies that evaluated satisfaction, the majority of patients reported high satisfaction after surgery. The overall complication rate (ranging from persistent pain and wound complications to nerve injuries and reruptures) after distal triceps tendon repair was 18.0%, the rerupture rate (complete and partial) was 7.2%, and the reoperation rate was 3.9%, with all partial reruptures undergoing nonoperative care. A distal triceps tendon rupture is a rare but potentially challenging injury, traditionally occurring in an active population, and often requires surgical repair. Importantly, >90% of an active-duty military population, athletes, and the general workforce was able to return to sport or their respective activity after surgery. Furthermore, there was high patient satisfaction and low rates of complications and reoperations after distal triceps tendon repair.

Comprehensive Analysis of the Clinical Outcomes, Lifestyle Impacts, and Family Satisfaction in Hirschsprung's Disease: A Retrospective Cohort Study from a Single Pediatric Surgery Unit

Background: Hirschsprung's disease (HD) is a congenital condition causing functional bowel obstruction. Despite surgical advancements, long-term impacts on patients' quality of life, family dynamics, and satisfaction remain underexplored. This study evaluates the clinical outcomes, lifestyle impacts, and family satisfaction in HD management. Methods: A retrospective cohort study analyzed 127 HD cases managed in a single pediatric surgery unit (2004–2020). Data from medical records, surveys, and structured interviews assessed surgical outcomes, postoperative bowel function, school attendance, dietary adjustments, social anxiety, and family satisfaction. The quantitative analysis utilized SPSS v25.0, with p-values <0.05 considered statistically significant. Results: Patients had a mean age at surgery of 10.6 months; 72.4% were male. Surgical interventions included one-stage pull-through (51.2%) and staged procedures (48.8%). Complications like persistent constipation (26.8%), enterocolitis (15.0%), and redo surgeries (6.3%) were common. Functional outcomes showed that 81.1% achieved good bowel function, while 14.2% required occasional medication. Rural patients faced higher absenteeism (45% vs. 30%) and restrictive dietary changes (50% vs. 35%). Family satisfaction was high (73.2%), with concerns about long-term bowel management (65%), psychosocial impact (38%), and financial burdens (21%). Conclusions: This study highlights the multifaceted challenges of HD management, including disparities in rural vs. urban care, persistent complications, and psychosocial impacts. Recommendations include multidisciplinary care, genetic counseling, family-centered support, and public health interventions tailored to regional needs. These findings advocate for enhanced strategies to improve surgical outcomes, address long-term care challenges, and elevate family satisfaction.

A proposed new classification system of hypothalamic hamartomas in the era of stereotactic ablation surgery.

Since the recent development of stereotactic ablation surgery, which can provide good seizure outcomes without limitations in size or location, conventional classification systems have become unsuitable for surgical guidance. The present study aimed to evaluate the validity of a newly proposed classification system focusing on the attachment pattern. This retrospective study investigated 218 patients with hypothalamic hamartomas who underwent MRI-guided stereotactic radiofrequency thermocoagulation and were followed for at least 1 year after their last surgery. Hypothalamic hamartomas were classified by their attachments into six subtypes: parahypothalamic-unilateral (PU), parahypothalamic-bilateral (PB), intrahypothalamic-unilateral (IU), intrahypothalamic-bilateral (IB), mixed-unilateral (MU), and mixed-bilateral (MB) types. Clinical features, surgical factors, scales of surgical procedures including numbers of trajectories and coagulations, requirement for a trans-third ventricular approach, reoperation rates, and complication rates were investigated. Seizure outcomes were evaluated separately for gelastic seizures (GSs) and non-GSs. In 218 patients (131 [60.1%] males, median age at surgery 7.2 [range 1.8-51] years), the hypothalamic hamartomas were classified as PU type in 10 (4.6%), PB type in 11 (5.0%), IU type in 41 (18.8%), IB type in 17 (7.8%), MU type in 40 (18.3%), and MB type in 99 (45.4%) patients. Patients with MB type were significantly younger at GS onset (p < 0.001) and surgery (p = 0.005). The numbers of trajectories and coagulations were significantly greater in MB type (p < 0.001) and the trans-third ventricular approach was more often required in the PB type (5/6, 83.3%, p < 0.001). Seizure outcomes were not different among subtypes. The rate of transient complications was not different among subtypes, but hyperthermia (p = 0.002) and hyponatremia (p < 0.001) were more frequently found in patients with PB and MB types. Prolonged or persistent neurological complications were also not different and were only found in bilateral subtypes. The new classification predicts clinical features, as well as surgical complexity and complications. Although seizure outcomes were not different among subtypes because the authors' surgical strategy is consistently based on complete disconnection at the border, the new classification could improve seizure outcomes and would be helpful in the appropriate guidance for surgery of hypothalamic hamartomas to provide consistently good outcomes regardless of surgical procedures.

The Induced Membrane Technique for Bone Defects in the Hand and Upper Extremity: A Case Series.

We present a series of cases in which the induced membrane technique (IMT) was used to treat segmental bone defects from trauma and chronic infection nonunion in the hand and upper extremity. The aims of the study were to present the rates of union and complications using this technique. Our institutional database was queried between 2012 and 2018. Patients who met the inclusion criteria with segmental defects either from acute trauma or chronic infection nonunion were included in the study. A retrospective review of their charts was performed documenting patient demographics, size of bone defect, time to union, mechanism of injury, and postoperative complications. A total of 13 patients met the inclusion criteria, and their individual charts and operative notes were reviewed. Eleven patients had acute traumatic bone loss, and the remaining 2 patients were treated for postoperative chronic infection nonunion as confirmed with positive cultures taken at the nonunion site. Rate of union after the index procedure was 84.6%, and average time to union was 14 weeks. The mean bone defect length was 2.73 cm. 46.1% of patients had soft tissue defects and complications requiring additional procedures for soft tissue coverage. The IMT is an alternative means of treating segmental bone defects in the upper extremity but can present with challenges resulting in persistent nonunion and complications with soft tissue reconstruction.

THE ACCEPTABILITY OF TELEMEDICINE IN POST-MASS CHARITY CIRCUMCISION IN INDONESIA: A PILOT STUDY

Introduction: Charity circumcision is common in Indonesia. It is usually done by general practitioners or medical students under supervision. Procedures are often held on a mass scale and rarely followed with post-monitoring. We developed a telemedicine follow-up protocol to educate and address post-procedure complications. This pilot study evaluates the acceptability of telemedicine follow-up protocol for charity circumcision in Indonesia. Method: Data were collected from operators and caregivers of children attending charity circumcision. The protocol consisted of text interviews (pain, urinary retention) and surgical sites' four-angle photographs (epithelialization, bleeding, infection, edema, and glans excoriation). The protocol was conducted two-way between caregivers and operators on days 1, 3, 7, and 30 after circumcision. The Ethics Committee of the Faculty of Medicine, Universitas Indonesia, has approved this study. Result: Twenty-five boys with a mean age of 8.02±1.53 years old have similar pre-operative, operative, and postoperative protocols. Twenty-one caregivers completed four times follow-ups, one missed two times follow-ups, and three missed the last follow-up. Mild pain was the most reported complication, with 32% (8/25), 12% (3/25), 8% (2/24) incidence on days 1, 3, and 7, respectively. By the end of the follow-up, there were no persisting complications, and 80% (20/25) of boys showed complete epithelialization. All caregivers and most operators were satisfied with telemedicine for post-mass circumcision monitoring. Conclusion: The telemedicine-based follow-up is acceptable and feasible to be applied in mass charity circumcision. This protocol is beneficial for monitoring the results and adverse events, therefore, should be routinely adopted in mass charity circumcision programs.

Psychosomatic Disorder: The Current Implications and Challenges.

In recent years, there has been increasing global concern about the rising prevalence and rapid progression of psychosomatic disorders (PD). This surge can be attributed to irregular biological conditions and the increasingly stressful lifestyles that individuals lead, ultimately resulting in functional impairments of vital organs. PD arises from intricate interactions involving the central nervous, endocrine, and immune systems. Notably, the hypothalamic-pituitaryadrenal (HPA) axis plays an essential role, as its dysregulation is influenced by prolonged stress and psychological distress. Consequently, stress hormones, including cortisol, exert detrimental effects on immunological function, inflammation, and homeostatic equilibrium. It emerges as physical symptoms influenced by psychological factors, such as persistent pain, gastrointestinal disturbances, or respiratory complications, and is pertinent to highlight that excessive and chronic stress, anxiety, or emotional distress may engender the onset or exacerbation of cardiovascular disorders, namely hypertension and heart disease. Although several therapeutic strategies have been proposed so far, the precise etiology of PD remains elusive due to the intricate nature of disease progression and the underlying modalities of action. This comprehensive review seeks to elucidate the diverse classifications of psychosomatic disorders, explicate their intricate mechanisms, and shed light on their impact on the human body, which may act as catalysts for the development of various other diseases. Additionally, it explores the inherent medico-clinical challenges posed by PD and also explores the cutting-edge technologies, tools, and data analytics pipelines that are being applied in the contemporary era to effectively analyze psychosomatic data.

An Association between Bilirubin and Diabetic Retinopathy in Patients with Type 2 Diabetes Mellitus: An Effect Modification by Nrf2 Polymorphisms

Background: Diabetic retinopathy (DR) is a persistent microvascular complication associated with diabetes, and it constitutes a significant cause of visual impairment and blindness. Aims: This study aimed to assess the correlation between serum bilirubin levels and the prevalence of DR in patients diagnosed with type 2 diabetes mellitus (T2DM). Additionally, we sought to establish whether the polymorphisms of Nuclear Factor E2-Related Factor 2 (Nrf2) might modify this relationship. Methods: A cross-sectional study was undertaken in Jiangxi, China, from May, 2012 to December, 2014. Serum bilirubin levels were assessed in 558 subjects, and the correlation between bilirubin and DR was analyzed using generalized linear models with a logit link. The study utilized odds ratios (OR) and 95% confidence intervals (CI) to evaluate the relationship, both with and without the consideration of clinical risk factors. Results: There was a significant inverse association between serum total bilirubin (TBiL) and the risk of DR (per 1-μmol/L increment; OR, 0.89; 95% CI: 0.84-0.94). Accordingly, when TBiL was categorized into tertiles, individuals in tertiles 2 and 3 exhibited significantly lower risks of DR compared to those in tertile 1. The OR for these tertiles was 0.54 (95% CI: 0.34-0.87) and 0.31 (95% CI: 0.19-0.52), respectively. Moreover, a stronger inverse relationship between TBiL and DR was observed in individuals carrying the CC and AC genotypes compared to those with the AA genotype. The OR for individuals with the CC/AC genotype was 0.87 (95% CI: 0.82, 0.92), while that for the AA genotype was 1.17 (95% CI: 0.95, 1.45). This difference was statistically significant (p for interaction = 0.001). Conclusion: There was a significant inverse association between bilirubin and DR in participants with CC or AC genotype. However, this inverse association was not seen in AA genotype participants.

Long COVID: A Comprehensive Overview of the Signs and Symptoms across Multiple Organ Systems.

Long coronavirus disease (COVID), also known as the post-acute sequelae of coronavirus disease 2019 (COVID-19) (PASC), is a significant concern since the end of the COVID-19 pandemic, as it still manifests in individuals with persistent symptoms and complications beyond the acute phase of infection. Defining this disease is challenging, as it manifests as a spectrum of symptoms varying in severity among individuals who have previously tested positive for COVID-19. Long COVID is more prevalent in hospitalized COVID-19 patients and presents in various ways, ranging from pulmonary to extrapulmonary symptoms. This literature review examines the current body of research on long COVID with a focus on its effects on the cardiovascular, hematological, respiratory, renal, and neurological systems with systematically analyzed, peer-reviewed articles retrieved from the PubMed database. There have been several proposed pathophysiological mechanisms by which severe acute respiratory syndrome coronavirus 2 affects the aforementioned organ systems; however, research on the definite mechanisms is lacking, especially when considering the management of long COVID in the perioperative setting. The impact of post-COVID sequelae necessitates individualized management strategies tailored to each symptomatic profile, particularly in patients with comorbidities. The COVID-19 pandemic affected millions of people and had a profound impact on those who developed PASC, lowering their quality of life and increasing potential surgical risks. However, there is still uncertainty regarding the specific risk factors for long COVID and who is most susceptible to it. Further research is required to fill these gaps and explore potential avenues for preventing PASC.

Harvi Cardiovascular Modeling Accurately Predicts Hemodynamic Improvements Produced by a New Direct Cardiac Compression Device.

Despite advancements in mechanical circulatory support (MCS) technology, persistent critical complications related to blood contact remain unresolved. To provide a safer alternative therapy, CorInnova is developing a non-blood contacting direct cardiac compression (DCC) device for MCS. To support product development toward clinical trials, a simulation platform has been developed to predict clinical outcomes under patient-specific conditions, guiding patient selection for clinical trials. The Harvi simulation was validated using preclinical in vivo data from experimental studies with the CorInnova device, with n = 28 hemodynamic samples simulated from animal data (n = 4 ovine). After confirming validation, further simulation was performed to predict additional hemodynamic outcomes not captured in animal studies. The simulated effects of CorInnova device therapy were not significantly different from animal data for cardiac output, systemic arterial blood pressure, mean pulmonary artery pressure, central venous pressure, or left ventricular pressure (p > 0.050). Harvi accurately predicts the effects of the CorInnova device in heart failure conditions and can be used in preparation for future clinical trials.

Versatility of the Pedicled Buccal Fat Flap.

The pedicled buccal fat flap (PBFF) is a versatile and robust regional flap used for a variety of maxillofacial reconstructions. However, recent literature has questioned the popularity of this flap. The goal of this single-instruction, retrospective study is to review the outcomes and complications of the PBFF. Our study included 27 patients and 28 PBFFs with 13 males, 14 females, and an average age of 68. The most common primary pathologies included squamous cell carcinoma and a fistula (oroantral or oronasal). Persistent postoperative complications were experienced in 31.3% of the cohort. The most common subsite was the retromolar trigone, and the higher complication rates per subsite were noted in the hard and soft palate groups (66.7% each). Higher total complication rates were seen in cases of SCC and fistula (33.3% each). Our study demonstrates the low morbidity and high tolerance of the procedure despite a patient having older age, significant comorbidities (67.9%), smoking history (60.7%), preoperative radiation (17.9%), and postoperative radiation (28.6%). The authors conclude the PBFF remains a durable and reliable reconstructive option in a variety of patient cases.

THERAPEUTIC APPLICATIONS OF EXTERNAL AYURVEDIC FORMULATIONS IN VRANA CHIKITSA: A COMPREHENSIVE REVIEW

Dushta Vrana (~chronic wounds or ulcers) present significant challenges in medical management due to their persistent nature and potential complications. Ayurvedic medicine offers a comprehensive approach to wound healing through various herbal formulations known for their anti-inflammatory, antimicrobial, granulation-promoting, and moisture-retaining properties. This review aims to explore the efficacy of different Ayurvedic formulations, including Malahar (~ointments), Taila (~medicated oils), Ghrita (~medicated ghee), and Lepa (~herbal pastes), in the treatment of Dushta Vrana and their role in enhancing the wound healing process. An extensive review of classical Ayurvedic texts and contemporary research was conducted to identify key formulations used in Vrana Chikitsa. The pharmacological properties of these formulations were analyzed, focusing on their anti-inflammatory, antimicrobial, granulation-promoting, and moisture-retaining effects. Ayurvedic formulations demonstrate significant efficacy in wound management. Anti-inflammatory herbs like Turmeric and Triphala modulate immune responses, reducing chronic inflammation. Antimicrobial agents such as Neem and Honey effectively inhibit the growth of pathogens, including antibiotic-resistant strains. Formulations like Jatyadi Malahar and Shatadhauta Ghrta promote granulation by stimulating fibroblast activity and collagen synthesis, while lipid-based Taila and Malahar ensure moisture retention, providing an optimal healing environment. Ayurvedic formulations offer a holistic and effective approach to the management of Dushta Vrana. Their multi-targeted actions not only address immediate wound care needs but also support long-term healing and tissue regeneration. Further research could solidify their role in modern clinical practice, enhancing the integration of Ayurvedic wound care into contemporary medical treatments.

Unveiling the heartbeat of hope: exploring cardiovascular morbidity, mortality, and socioeconomic threads in 65,173 Child, Adolescent, and Young Adult (caya) cancer patients

Abstract Background Despite significant progress in managing cancer in children, adolescents, and young adults (CAYAs), persistent complications impact their quality of life with some being severe or life-threatening.(1,2) Long-term outcomes depend on common risk factors for malignancy and cardiovascular diseases (CVD) that overlap, and treatments are known to increase the risk for CVD. (3,4) Healthcare inequality due to socioeconomic status is omnipresent and may significantly impact outcomes. Purpose This study aims to comprehensively cover morbidity, mortality, demographic, and socioeconomic factors among CAYAs and investigate their impact on cardiovascular outcomes. Methods This retrospective matched cohort study included the entire Swedish population under 25 with cancer from 1958 to 2021. The study population was identified from the National Board of Health and Welfare's Cancer Register, with controls paired 1:5 based on age, sex, and residence. Multiple registers provided data on morbidity, mortality, and demographics. Results Covering 63 years, identified 65,173 CAYAs (1.24 million patient-years) and matched with 312,935 controls (7.45 million person-years), a total of 378,108 individuals (74% females). The mean follow-up was 19.5 (SD16.9) years for CAYAs, and 23.8 (16.8) for controls, (p&amp;lt;0.001). At the end of the study, the median age of CAYAs was 33.4 (IQR 27.9) years and controls 39.2 (28.3) (p&amp;lt;0.0001), with an age span of &amp;lt;1-88 years in both groups. CVD was detected in 16.9 % of the CAYAs, representing a 1.21-time elevated risk (95% CI 1.18-1.23, p&amp;lt;0.0001) compared to controls. CAYAs had a higher mortality rate, and 5-years survivors lived a mean of 26.9 years shorter than controls. CV mortality was also increased in CAYAs, (1.9% compared to 0.7% in controls) but at a higher age, although at a mean of 22.8 years younger than their controls. The 5-year survivors were older at CV mortality and lived in mean 6.5 years shorter than controls (p&amp;lt;0.0001). After adjusting for socioeconomic factors, individuals born outside Europe and those with greater sick leave had a higher mortality risk, while education and marriage showed a beneficial association with mortality. (p&amp;lt;0.0001). Interpretation The Rebuc study, spanning six decades, revealed a significantly increased risk of serious complications among young cancer patients in Sweden. Not only do young cancer patient survivors face a significantly higher risk for cardiovascular disease, but the higher mortality risk before middle age also underscores the severity of the health challenges they confront. Furthermore, these young individuals are more susceptible to socioeconomic factors that may adversely affect their survival.

Kawasaki Disease in Somalia; A Case Report and Literature Review

Abstract: Kawasaki disease (KD) is a prevalent form of vasculitis in childhood, primarily affecting infants and young children. This leads to persistent cardiovascular complications resulting from coronary artery damage. Despite various hypotheses, the exact cause of this disease remains unknown. We present a case of Kawasaki disease in a one-year-old boy who exhibited one week history of high fever, rash, and conjunctivitis. The clinical manifestations progress, beginning with fever during the acute phase. Subsequently, non-purulent bilateral conjunctival redness developed, followed by changes in the mouth, such as red and cracked lips, along with a reddish tongue (strawberry tongue). This was achieved by one-sided cervical lymphadenopathy (with one node exceeding 1.5 cm in diameter), and within five days of fever onset, polymorphous rashes emerged. The patient was diagnosed with typical Kawasaki disease, and treatment was initiated with acetylsalicylic acid at a dose of 50 mg/kg/day and intravenous immunoglobulin (IVIG) at a dose of 2 g/kg. The diagnostic criteria for Typical Kawasaki disease include both the Japanese working guidelines and the American Heart Association guidelines, which further categorize the disease as typical or atypical. Treatment with intravenous immunoglobulin (IVIG) and aspirin (ASA) during the acute phase significantly reduced the risk of coronary abnormalities by approximately 5%. In summary, Kawasaki disease is infrequently documented in sub-Saharan countries. The uncommon presentation and rarity of the disease pose challenges for diagnosis, particularly in sub-Saharan Africa, notably Somalia, where no cases have been reported to date.

Is Postoperative Voiding Cystourethrogram Routinely Indicated Following Robotic-assisted Laparoscopic Ureteral Reimplantation in Children: Time to Define the New Standards?

ObjectiveTo examine the need to routinely obtain VCUG to confirm vesicoureteral reflux (VUR) following robotic-assisted laparoscopic ureteral reimplantation (RALUR) in children. MethodsA single-center prospectively maintained database was reviewed for patients <18 years old who underwent RALUR for VUR. Patient charts were reviewed for baseline characteristics and surgical details. Patients were routinely followed up by renal bladder ultrasound at 6-8 weeks and VCUG at 3 months postoperatively. The primary endpoint was radiological success defined as the absence of VUR on postoperative VCUG. The secondary endpoints were clinical success, defined as the absence of postoperative febrile UTI, postoperative urinary retention, and reoperation for persistent VUR or RALUR complications. ResultsBetween 2018-2023, 42 children (48 refluxing ureters) underwent extravesical RALUR at the study institution at a mean age of 70.4+23.7 months. A majority of 81% were females and 85.7% had associated bladder and bowel dysfunction. Six patients (14.3%) had bilateral RALUR. Of the ureters, 83.4%(40/48) had grade III or higher VUR and 20.8%(10/48) had duplex kidneys. Postoperative VCUG was completed in 36(85.7%) patients. Radiological reflux resolution was confirmed in 87.5%(35/40) of ureters. The remaining 5 ureters had VUR downgrading to grade I or II; all remained asymptomatic and none required reoperation. One patient required ureteral stenting for 6 weeks for an unidentified unilateral ureteral injury without long-term consequences. Postoperative urine retention requiring short-term catheterization occurred in 3 patients. The clinical success rate was 97.6%. ConclusionAfter bypassing the learning curve, VCUG is not routinely indicated following RALUR for VUR.

Oral Liposomal Iron Versus Injectable Iron Sucrose for Anemia Treatment in Non-dialysis Chronic Kidney Disease Patients: A Non-inferiority Study.

Introduction Anemia is a prevalent and persistent complication in chronic kidney disease (CKD), particularly in advanced stages, contributing to the deterioration of renal function and diminishing patients' quality of life. Iron supplementation constitutes a cornerstone of anemia management in this population. Among various iron formulations, liposomal iron has emerged as a promising option due to its enhanced efficacy in replenishing iron reserves and improved tolerability. Objective This study aims to assess the comparative effects of intravenous and liposomal oral iron on hemoglobin levels in non-dialysis CKD patients. Additionally, it seeks to evaluate the rate of hemoglobin correction, iron reserve status during treatment, and therapeutic tolerance to these interventions. Materials and methods A randomized controlled trial enrolled CKD patients (stages 3-5, not on dialysis) with iron deficiency anemia (hemoglobin ≤ 12 g/dL, ferritin ≤ 100 ng/mL, transferrin saturation ≤ 25%). Participants were allocated to receive either daily oral liposomal iron (Group OS) at a dosage of 30 mg or intravenous iron-hydroxide sucrose complex weekly (Group IV) for three months. Follow-up extended through the treatment phase and two months post-withdrawal. Results Thirty-one CKD patients were randomized into two groups: 14 received intravenous iron (IV group) and 17 received oral iron (OS group). After excluding four patients, the final cohort comprised 27 individuals (IV group: n=13, OS group: n=14). Both iron treatments resulted in progressive hemoglobin increases, with the IV group showing a mean increase of 14.65% (p=0.049) compared to 4.78% (p=0.003) in the OS group. Secondary analysis revealed significant increases in ferritin levels (p<0.001) and transferrin saturation (TSAT) levels (p=0.031) in the IV group. Post-treatment follow-up demonstrated stable hemoglobin levels in the OS group and a consistent increase in ferritin levels in the IV group. Adverse reactions predominantly included hypotension in the IV group (4 (30.7%)) and constipation in the OS group (4 (28.4%)). Discussion and conclusion Anemia remains a significant challenge in CKD patients. Our study compares oral liposomal iron to injectable iron for anemia treatment, aiming to minimize hospitalizations for iron infusion, preserve venous capital, and mitigate potential harmful side effects. We found oral liposomal iron to be a safe and effective option for correcting anemia in non-dialysis CKD patients, albeit with lower efficacy in replenishing iron stores compared to IV iron. Comparative analysis with similar studies supports the non-inferiority of oral liposomal iron, although IV iron retains superiority in replenishing iron reserves.

Treatment outcomes and their predictors in children hospitalized with varicella complicated by bacterial superinfections after pandemic of COVID-19 – a retrospective multicenter analysis of real-life data in Poland

PurposeThe aim of this study was to analyze treatment outcomes and their predictors in children hospitalized due to varicella complicated by bacterial superinfections after pandemic of COVID-19.MethodsThis retrospective study analyzed data collected in a multicenter, nationwide, observational database dedicated for children aged 0–17 years hospitalized due to bacterial complications of varicella in 9 Polish tertiary healthcare inpatient centers. The primary endpoint of this study was the treatment outcome established after the end of hospital management assessed at a 4-point scale. The secondary endpoint was defined as the necessity of surgical intervention.ResultsThere were 458 patients with a median age of 4 (IQR 2–6) years. After the completed treatment, 319 (69%) participants were found fully recovered; 132 (29%) had transient complications; 2 (0.5%) had persistent complications; and 1 child (0.5%) died. Multivariate analysis revealed that implementation of ibuprofen in pre-treatment management of a child with varicella was associated with a 4.07-fold (2.50–6.60) increase in risk of complications after the treatment and it was associated with 2.87 times (1.39–5.89) higher risk of surgical intervention necessity. For other pre-hospital interventions (implementation of acyclovir, antibiotics or antihistaminics) no significant impact was observed. GAS infection increased the necessity of surgical intervention by 7.51 (3.64–15.49) times.ConclusionsOne-third of patients treated for bacterial complications of varicella have post-treatment complications, most of them transient. GAS infection increases the need for surgical intervention. The use of ibuprofen in the treatment of varicella significantly increases the risk of complications and the need for surgical intervention.

Review article: Telerehabilitation interventions for rehabilitation and management of post-COVID-19 patients: A comprehensive review

The COVID-19 pandemic has posed significant challenges to healthcare systems worldwide, impacting patients during the disease’s acute and post-acute phases. Telerehabilitation has emerged as a promising approach to address the rehabilitation needs of individuals recovering from COVID-19. This comprehensive review examines the effectiveness and feasibility of telerehabilitation strategies for managing post[1]acute COVID-19 symptoms and promoting recovery. Through a systematic review and meta-analysis, various studies have demonstrated the potential benefits of telerehabilitation interventions in improving functional capacity, exercise perception, and quality of life among post-COVID-19 patients. Telerehabilitation programs have been successfully implemented across primary care settings, offering supervised home-based exercise training that targets physical and respiratory functions. Moreover, innovative tools such as mobile applications have been employed to enhance patient engagement and track progress. While the evidence indicates positive outcomes, there is a need for further investigation to explore the effects of telerehabilitation on additional variables such as cardiopulmonary function, anxiety, depression, and long-term outcomes. Despite limitations, telerehabilitation has shown promise in addressing the persistent symptoms and complications associated with post-acute COVID-19 syndrome. The integration of telerehabilitation into clinical care frameworks has the potential to improve patient access, engagement, and overall recovery during the ongoing pandemic and beyond. Continued research and development are essential to optimize telerehabilitation strategies for long-term COVID-19 management.

Analysis of nasal fracture management and subsequent surgical outcomes across demographics.

Nasal bone fractures are the most common type of facial injury and can pose significant long-term challenges if not diagnosed and treated correctly at the time of presentation, including, but not limited to, septal hematoma, infection, epistaxis, persistent nasal deformity, nasolacrimal injury, deviated septum, and even mental health issues as serious as post-traumatic stress disorder as persistent complications (1-4). Optimal management remains controversial and subjective based on the clinician's judgment, with many factors playing a role in the provider's decision, including the timing of treatment, the choice between foregoing treatment or choosing to undergo a closed or open reduction, and how to manage subsequent revision surgeries if necessary.

Metabolic theory of preeclampsia: implications for maternal cardiovascular health.

Preeclampsia (PE) is a multisystemic disorder of pregnancy that not only causes perinatal mortality and morbidity but also has a long-term toll on the maternal and fetal cardiovascular system. Women diagnosed with PE are at greater risk for the subsequent development of hypertension, ischemic heart disease, cardiomyopathy, cerebral edema, seizures, and end-stage renal disease. Although PE is considered heterogeneous, inefficient extravillous trophoblast (EVT) migration leading to deficient spiral artery remodeling and increased uteroplacental vascular resistance is the likely initiation of the disease. The principal pathophysiology is placental hypoxia, causing subsequent oxidative stress, leading to mitochondrial dysfunction, mitophagy, and immunological imbalance. The damage imposed on the placenta in turn results in the "stress response" categorized by the dysfunctional release of vasoactive components including oxidative stressors, proinflammatory factors, and cytokines into the maternal circulation. These bioactive factors have deleterious effects on systemic endothelial cells and coagulation leading to generalized vascular dysfunction and hypercoagulability. A better understanding of these metabolic factors may lead to novel therapeutic approaches to prevent and treat this multisystemic disorder. In this review, we connect the hypoxic-oxidative stress and inflammation involved in the pathophysiology of PE to the resulting persistent cardiovascular complications in patients with preeclampsia.